Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study

OBJECTIVES

Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM).

METHODS

We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined.

RESULTS

Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal.

CONCLUSIONS

Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.

Revealing tacit knowledge used by experienced health professionals for interprofessional collaboration

With the current interest in interprofessional collaboration in health care as a response to ever-increasing complexity of health issues and scarcity of resources, many higher education institutions are developing interprofessional education (IPE) programs. However, there has been little empirical work on what. With the current interest for interprofessional collaboration in health care ever-increasing knowledge and skills are required to work collaboratively between health professions. We have undertaken to describe interprofessional collaboration as a practice largely underpinned by tacit knowledge acquired by experienced clinicians. Clinicians from all health professions in a large francophone university in Eastern Canada were invited to participate in explicitation interviews. Explicitation interviews require participants to freely recall an interprofessional collaboration event (e.g., team meeting or joint care delivery) and describe specific actions they personally enacted. An experienced health professional encounters many interprofessional situations over time; the actions they describe reflect their personal theories about the practice. Hence, it is highly probable that they use them frequently when working with colleagues in clinical settings. Unveiled tacit knowledge was divided into four themes: the importance of a sense of belonging to a team, the imperative to meet face-to-face, the practice of soliciting the working hypotheses of colleagues, and the art of summarizing meeting discussions.

BiVADs: a bridge to the future for patients and their families: the art and science of nursing combined in the face of technology

Approximately 500,000 Canadians live with heart failure (Ross et al., 2006). These numbers continue to rise due to advancing technology and successes in treating cardiac conditions and potentially fatal events such as myocardial infarctions. According to Carrier (2005), individuals with damaged hearts are living longer, and lives are being successfully saved with the surge of cardiovascular assist devices developed in recent years, which are increasingly used as a bridge to transplant. Despite the lifesaving capabilities of ventricular-assist devices, these innovations pose risks and complications that can be debilitating for patients and their families (Carrier, 2005). As this complex trajectory is navigated, nurses provide care and support to the patient and family while playing a unique role in the assessment and monitoring of these devices. A family-centred nursing model provides a framework for practice when nursing patients and families are in crisis. The foundations of the McGill Model of Nursing are focused on a strengths-based approach, revolving around collaboration between patients, family resources, and tailored interventions (Gottlieb & Feeley, 2005). As students placed in a critical care setting, we began to realize the complexity of care required to nurse these patients and their families. In this paper, a case study is used to describe and share our learning experiences of caring for a patient with a biventricular assist device, as well as the principles that guided our interventions.

Clover and cress as indicator species of impacts from limed sewage sludge and landfill wastewater land application

This study evaluated the performance of cress and clover as bioindicators to evaluate the impact of limed sewage sludge and landfill wastewater application on soil. The use of these two species, and the subsequent parameters measured, were also compared for their effectiveness in evaluating potential effects. Sewage sludge was added to the soil at a rate of 23 mg ha-1 and also at twice this dose. Wastewater was added at a level of 2 and 10% of the soil volume. Germination rate, height increase per week and final dry biomass were measured for both species. Heavy metal (Cd, Pb, Fe, Cu, Ni, and Zn) concentration was determined only for the shoot and root of clover. In general, the results showed that, compared to the control, the overall performance improved for plants exposed to both treatments. However, plants appeared to respond better to the wastewater addition than the sewage sludge amendment. The germination rate as well as other traits indicate that clover may be more sensitive to these fertilizers than cress. The lime addition did not appear to influence growth, nor heavy metal accumulation in clover. There were major differences in heavy metal accumulation in the root vs. shoot of clover. Hence, the concentrations of Cd, Cu, Fe, Zn, and Pb did not vary in the shoots of the plants under either treatments. The concentrations of the heavy metals in the roots however, greatly varied according to the type of metals. The concentrations of these metals appeared to increase with the increase of the addition treatments. The results suggest that for both species, the levels of fertilizers used in the present study were below the toxicity levels. Since the types of soils and the doses of fertilizers influence the rate of heavy metal absorption and their effects on plants, methods for rapid evaluation/monitoring as well as the types of indicators used should be explored as in the present study.

Bedside coagulation monitoring in heparin-treated patients with active thromboembolic disease: a coronary care unit experience

Patients with active venous and arterial thromboembolic disorders are known to benefit from systemic anticoagulation with heparin. Clinical studies have shown, however, that therapeutic anticoagulation is rarely achieved rapidly and often is not maintained over time. Prolonged laboratory turnaround time of the activated partial thromboplastin time (aPTT) may contribute directly to these common problems. A total of 272 aPTT determinations were performed on 120 heparin-treated patients admitted to the coronary care unit. The time from sample collection to data availability was 126 +/- 84 minutes with standard laboratory aPTT testing. In contrast, a bedside coagulation device provided an aPTT within 3 minutes (p < 0.001). Subtherapeutic aPTT values (< 65 seconds) were documented in 21% of all patients; in each, the heparin dose was changed and a repeat aPTT was required. In a separate study of 33 heparinized patients randomized to either bedside or central laboratory aPTT testing (264 aPTT determinations), the time to achieve a therapeutic state of systemic anticoagulation was 8.2 hours and 18.1 hours, respectively (p < 0.005). The time from aPTT determination to a decision regarding heparin titration adjustments was 14.5 minutes and 3 hours with bedside and laboratory testing, respectively (p < 0.001). Thus bedside coagulation monitoring provides a convenient, rapid, and accurate assessment of systemic anticoagulation among heparin-treated patients with active thromboembolic disease in the coronary care unit. This technology warrants further clinical investigation.

A joint effort in cost containment at the University of Massachusetts Medical Center

The author discusses how nursing management of a critical care unit at the University of Massachusetts Medical Center worked with material management to reduce inventory and storage space. He also discusses how nursing attitudes toward cost containment need to be developed before they go to work at a healthcare facility.

Regionally selective roles of the rat's striatum in modality-specific discrimination learning and forelimb reaching

Rats with ibotenate lesions of either the medial striatum or the lateral striatum were trained in a forelimb reaching task and in acquisition, retention and reversal of either turn (left-right) discrimination or brightness (black-white) discrimination in a cross-shape maze. Compared with the controls, the rats with lesions of the medial striatum showed a reliable, modality-selective impairment in reversal of turn discrimination, but no significant impairment of reaching. In contrast, the rats with lateral striatal lesions showed a significant impairment of forelimb reaching, but not of reversal of either discriminations. Neither medial nor lateral lesions significantly affected acquisition and retention of both discriminations. The findings indicate a predominant role of the medial striatum in monitoring of directional responses, confirm the regionally specific role of the lateral striatum in reaching, and are interpreted to support the hypothesis of parallel motor and cognitive forebrain circuits comprising distinctive regions of the striatum.

Effects of age and regular exercise on muscle strength and endurance

Twenty male and 20 female non-professional tennis players were classified into two different age groups (n = 10 per group): young active men (30.4 +/- 3.3 years), young active women (27.5 +/- 4.3 years), elderly active men (64.4 +/- 3.7 years), and elderly active women (65.3 +/- 4.5 years). These individuals were matched (n = 10 per group) according to sex, age, height and mass to sedentary individuals of the same socio-economical background: young sedentary men (29.2 +/- 3.4 years), young sedentary women (25.6 +/- 4.4 years), elderly sedentary men (65.2 +/- 3.2 years) and elderly sedentary women (65.6 +/- 4.4 years). An isokinetic dynamometer was used to measure the strength of the knee extensors and flexors (two separate occasions) and the endurance of the extensors. Vastus lateralis electromyogram (EMG) was measured concomitantly. Significant sex, age and exercise effects (P less than 0.001) were observed for peak torque of both muscle groups. The effect of age on extensor strength was more pronounced at high speeds where men were also able to generate larger relative torques than women. No age or sex effects were noted for muscle endurance. However, muscles of active individuals demonstrated a greater resistance to fatigue than those of sedentary individuals. In conclusion, men were found to be stronger than women, age was associated with a decrease in muscle strength, but not of muscle endurance, and tennis players were stronger and had muscles that were more resistant to fatigue than their sedentary pairs in both age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Fast Track: urgent care within a teaching hospital emergency department: can it work?

We performed a ten-week study to understand the feasibility of a fast track system within a teaching hospital setting. Our results show that 50% or fewer of patients entering an emergency department during evening and weekend day hours can be seen in Fast Track. Average turnaround time for all patients in the ED was 161 minutes. The average for all Fast Track patients was 94.5 minutes; if laboratory and/or radiographs were ordered the average was 121.5 minutes; with no laboratory/radiographs, 79.1 minutes. Urinalysis, strep screen, and complete blood count accounted for 80% of all laboratory work. Roentgenograms of the ankle, foot, and knee accounted for 80% of all radiographs. An evaluation questionnaire showed enhanced satisfaction with a reduction in the number of complaints from 79% to 22%. The Fast Track system failed when there was a predominance of acutely ill patients in the ED, as house officers were pulled to care for the acutely ill patients.

Performance on cognitive tasks in predicting the behavioral competences in the institutionalized elderly

The questions under consideration concern quantitative and qualitative aspects of the relationship between cognitive abilities and behavioral competences in the elderly institution residents. The former was assessed by an array of five cognitive measures, namely, two Piagetian tasks, Set Test, WAIS Vocabulary and Digit Span subtests and the WMS Associative Learning subtest and the latter by the Stockton Geriatric Rating Scale (SGRS). The overall variance in common between the two sets of variables was approximately 70 percent. Of the cognitive tasks, those most highly predictive of behavioral competences were the Piagetian tasks, Set Test and, to a lesser extent, WAIS Vocabulary subtest. Of the four SGRS factors, that predicted to the greatest extent was apathy, with physical disability to a lesser extent.